So Much to Learn, So Little Time

At Dallas’ Southwestern Medical School, one of the nation’s best research institutions, students not only have to master an exploding body of scientific knowledge—they also must learn to deal with social problems and a changing marketplace. No wonder becoming a doctor is harder than ever.

“YOU REALLY ONLY NEED TO KNOW THREE THINGS about medicine,” Dr. Steve Lacey explained to the gathering of 207 first-year students at Southwestern Medical School in Dallas this past fall. “One is, Oxygen is good! The second is, The blood goes round and round! And the third is, You have to make pee!”

The students got a big laugh out of Lacey’s lighthearted riff during the opening lecture of first-year biochemistry. But they were much too bright to have missed the more sobering irony beneath the humor. Medical knowledge has burgeoned to such a degree that it is all but impossible for aspiring doctors to master it. The knowledge glut would seem to demand even more of the specialization that has been the trend in medicine for the past quarter of a century. But the marketplace is demanding exactly the opposite—more primary-care physicians. Today’s generalists have to know everything about medicine, from Lacey’s three basic rules to the latest scientific developments, and they have to know how to run a cost-efficient clinical practice as well.

“Your medical education will not be completed in four years,” Lacey told them later in the lecture. “The nature of education has changed for you in a very dramatic way. In the past the teachers taught, you went to class, you did what they said, you got a grade. Well, I’ve got a news flash for you: I don’t care about your grades. The real test is coming five years from now, when you’re in the sack at two o’clock in the morning, and a nurse calls you about a problem with a patient. Do you know enough to take care of him?”

Not so long ago, deciding to be a doctor involved only certainties: Years of hard study would be rewarded with high income and equally high prestige. But the continuing explosion of biomedical knowledge guarantees that much of what today’s students are learning will be outdated by the time they graduate, necessitating rigorous and constant reeducation for the rest of their careers. Meanwhile, the vagaries of the marketplace dictate that there is no longer the certitude of big money at the end of the gauntlet. And for the first time in the history of the profession, there is a growing mistrust of doctors. “I can think of lots of other things I could do to make money,” observes first-year student Leslie Chin of Dallas, a 22-year-old second-generation Chinese American who was a National Merit Scholar and an honor graduate of UT-Austin. “But I can’t be concerned about making money. And I can’t be concerned about making A’s either. I just have to focus on remembering what’s going to make me a good doctor.”

For Southwestern, an institution that in fifty years has gone from educating students in army barracks to a $400 million medical center with three Nobel prizes to its name, the task of providing her with that knowledge may be its most daunting challenge yet. At Southwestern and other leading medical schools, the dueling forces of expanding knowledge and restrictions on the use of that knowledge imposed by the managed-care revolution have compelled reflection and innovation for the first time in decades. Curriculum is being rethought, training refashioned. Students are being educated by doctors who have scant experience with the realities of the modern medical marketplace. In many ways the job of having to learn too much, too fast is one that the students will have to do on their own.

“There was a time, I suppose,” says Southwestern’s dean, Dr. William Neaves, “when all that a doctor needed to know was uttered at one time or another during his medical education. No more. My ideal finished student today would be one who is grounded in all the basics we can offer in four years, but also has learned how to manage time and information and how to keep on learning.” Add to this the growing economic pressure on physicians—their two main sources of income, insurance companies and government, are cutting back—and the decision to become a doctor becomes an adventurous, if not risky, career choice.

Like Cauliflower

IN A LARGE, DANK ROOM MARKED “GROSS ANATOMY”—a double meaning that is all too apt—dozens of partially mutilated cadavers lie on stainless steel gurneys. Each grayish corpse is attended by four or five impossibly young first-year medical students, who today are taking a hands-on look at the anatomy of the heart. The greenish light and the odor of embalming fluid are oppressive. But the students seem oblivious to the environment as they carve and probe their cadavers, consult anatomy texts, exchange questions and answers with two roving professors, and attempt to finish the afternoon’s work: identification of some fifty body parts. The students have already listened to an hourlong lecture on the heart; now it’s time to put to use what the professor was talking about.

This is one of the few things about medical education that is more or less the same as it was more than thirty years ago, when internal medicine professor John Burnside studied anatomy. “Anatomy is the baseline still,” says the wiry, avuncular doctor, who is escorting me through the lab. “There has been some talk about changing this too, using computer imaging, cyberanatomy. But so much of understanding the body is three dimensional, and so much of it is texture.”

A young female student (the first-year class is almost 40 percent women) approaches to ask Burnside about a mass of tissue in her cadaver that she is having trouble identifying. Burnside goes over to inspect the cadaver, which, at midsemester, has begun to look like a well picked-over Thanksgiving turkey. “Those are juicy lymph nodes,” he says. “Metastasized. This patient died of cancer.”

“They’re kind of like cauliflower,” the student says, continuing to poke at the tissue.

Burnside returns to our conversation. “These students keep the same cadaver for the whole semester, and they frequently develop a relationship with it,” he says. “They learn all the organs,

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